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TIPS AND TRICKS OF CENTRAL LINE CARE

May 15, 2017

Kaniska Young Tai (Kyt), Outreach Program Coordinator, The Hospital for Sick Children, Toronto

Monica Kaszycki, Clinical Educator/RN, Children’s Hospital, London Health Sciences Centre

Patti Bambury, POGO Satellite Nurse Coordinator, Grand River Hospital, Kitchener



Disclaimer

We have no financial arrangements with any of

the brands we discuss today.

There are no financial conflicts of interest to

declare.



Outline

In this presentation, we will be discussing:

• Overview of lines

• CLABSI

• Line care

• Troubleshooting

• Quiz (the prize is chocolate)

• Demonstrations and hands on opportunity

• Open discussion



Disadvantage of an implanted port is that it

a. affects bathing and swimming practices

b. requires daily heparin flushes

c. utilizes a needle to access it

d. is not available for use in infants



Partial withdrawal occlusion occurs when

a. the catheter cannot be flushed or aspirated

b. a drug precipitate blocks the line

c. blood is easily aspirated, but the line will not flush

d. the line flushes easily, but blood is unable to be aspirated



If bacteremia is suspected in a CVL, it is important for the nurse to

a. start a peripheral IV and not use the CVL

b. flush BID with heparin to keep the line open

c. deliver antibiotics, alternating catheter lumens if there are multiples

d. change the dressing daily



If a CVAD appears to be clotted from blood, an appropriate action would be to instill

a. 1,000 u of heparin in an attempt to dissolve the clot

b. 1–2 mL of TPA in an attempt to dissolve the clot

c. 0.1% HCl acid to try to dissolve the clot

d. 70% alcohol to try to dissolve the clot



Jonny is a 4 year old that has been diagnosed with ALL. What type of line will he receive?

a. Port-a-cath

b. Double lumen hickman

c. PICC

d. What the family chooses



Which one is not one of the 4 moments of hand hygiene?

a. Before you enter the room

b. Before interacting with patient

c. Before talking to the parents

d. After you leave the room

e. After touching body fluids



What is the appropriate size of syringe to use when accessing a central line?

a. 1 cc

b. 3 cc

c. 10 cc

d. 60 cc



Which of the following is considered to be a central venous line:

a. All of the above

b. Triple-lumen catheter, port-a-cath, PICC

c. Port and PICC

d. Port-a-cath and triple-lumen catheter

• Triple-lumen catheter

• Port-a-cath

• PICC

• Midline catheter



What are the signs of a CVL occlusion?

a. All of the above

b. i, ii, iii

c. i, iii, v

d. i, ii, iii, v

i. Inability to withdraw blood or sluggish blood return

ii. Sluggish flow

iii. Inability to flush or infuse through the CVL

iv. Frequent occlusion alarms on electronic infusion device

v. Infiltration/extravasation or swelling and leaking at infusion site



Key components of the central line maintenance bundle include:

a. Hand hygiene, proper PPE, skin prep

b. Proper PPE, Hand hygiene, skin prep, inspection of site, catheter and dressing

c. Skin prep and inspection of the site

d. Inspection of site, catheter and dressing



What is a Central Venous Line

• A long, flexible catheter tube which is inserted in the arm or chest through the skin into a large vein leading to the heart.

• Its purpose is to provide long-term vascular access for:– IV fluids

– Medications

– Blood sampling

– Infusing blood products

• Strict aseptic technique is used



Non-Tunneled CVL/Venous Access Port/PICC Line



What can a central line be used for?

a. Nutrition

b. Hydration

c. Medications

d. Blood transfusions

e. All of the above



Non-Tunneled CVL/Venous Access Port/PICC Line

CVL PICC LINEPORT-A-CATH



Choosing the “Right” CVAD

• Purpose

– Disease

– Planned therapy

• Patient/Family factors

– Lifestyle

– Age/Size/Weight

– Patient preference

• Home health resources

• Maintenance costs

18



Port-a-Cath



A port is always inserted on the right side of the patient’s chest to avoid the heart

which is on the left.

a. True

b. False



Assessing and Deaccessing a Port-a-Cath

Feel the soft top of the

port to locate the

three palpation bumps

arranged in a triangle

Feel the sides of the

port to identify its

unique triangle shape



Assessing and Deaccessing a Port-a-Cath

Video on Assessing and Deaccessing a Port-a-Cath



CVL Dressing Change



When accessing a port of an oncology patient you always use a 1” needle.

a. True

b. False



Central Line Dressing Change

Video on Central Line Dressing Change



Central Line Cap Change

Video on Central Line Cap Change



All tertiary centres follow the same procedure for locking of central lines?

a. True

b. False



LOCKING LINES

When heparinizing a central line, what is your policy DOSE (in ml or units)

(How frequently do you require heparinized lines to be flushed)

Port-a-CathHickman/Broviac

LinePICC Line

Tertiary Centre 1

3ml/100 units

(Every 4-6 weeks)

3ml/100 units

(Weekly)

5ml/100 units

(Weekly)

Tertiary Centre 23cc 1:100u heparin

(Monthly with re-heparinization)

1.5cc 1:100u heparin

(Weekly with re-heparinization)

2cc 1:100u heparin

(Daily with re-heparinization)

Tertiary Centre 3

Weight based, (10 units per kg),

max dose 300 units (100units/ml)

total volume of 3ml.

(Every 4-6 weeks)

100 units (100units/ml), total volume

of 1 ml.

(Minimum q24h)

100 units (100units/ml), total volume

of 1 ml.

(Minimum q24h)

Tertiary Centre 4

100 units/mL, 3-5mLs

(Whenever they are capped off

and q4 weeks)

Don't use heparin for these lines non-valved: 10 units/mL, 1-2 mLs,

valved: don't use heparin

(non-valved: when capped off and

daily)



What is a CLABSI

• A CLABSI (central line associated bloodstream

infection) is a primary bloodstream infection

(BSI) in a patient that had a central line within

the 48-hour period before the development of

the BSI.



CLABSIs

• Migration of skin organisms at the insertion sit

into the cutaneous catheter tract with

colonization of the catheter tip is the most

common route of infection

• Contamination of the catheter hub also

contributes to intraluminal colonization of long-

term catheters

• Rarely, contamination of the infused fluid leads

to infection



CLABSIs

• Localized

– Erythema/Swelling• Exit site

• Over port reservoir

• Along catheter tract (tunnel)

– Drainage at exit site• May be absent with neutropenia

• Systemic

– Fever/Chills

– Usually can be cleared with antibiotics• Alternate antibiotics between lumens

31



CLABSI Prevention

• All centres will have an evidenced based policy

for Central Line Maintenance Bundle.

Key components of the bundle include:

• Hand hygiene

• Proper PPE

• Skin prep

• Inspection of site, catheter and dressing



CLABSI Prevention



CLABSI Prevention

4 moments of hand hygiene! Using either an

Alcohol Based Hand Rub (ABHR) or an

antimicrobial liquid soap solution.



CLABSI Prevention

• Scrub the hub using antiseptic swabs!!



Patient is febrile and neutropenic and has a CVL that is infected at the sight you would always see

inflammation or redness at the site.

a. True

b. False



Troubleshooting

Line dysfunction can be:

• Non-thrombotic

• Thrombotic



Non-Thrombotic Occlusions

• Patient position

• Closed clamps

• Improper needle positioning (Port-a-cath)

• Kinked tubing

• Cracks or leakage in CVC

• Catheter tip migration

• Malposition of the catheter



Thrombotic Occlusions

• 4 types of thrombotic catheter occlusions:

– Intraluminal Thrombus

– Fibrin Tail or Flap

– Mural Thrombus

– Fibrin Sheath



Thrombotic Occlusions: Fibrin Sheath

Fresh Fibrin sheath Adhered Fibrin sheath

Fibrin sheath with cuff Organized Fibrin sheath

Mokrzycki MH, et al. Kidney International Sept 2010 78:1218–31.

Salgado OJ. Vascular Access for Hemodialysis. Overview and Emphasis on Complications 2013.

Vaccharajani TJ. Atlas of Dialysis Vascular Access 2010.




• Acts as a one-way valve that permits infusion

but not withdrawal of fluid from the catheter

Aspiration:the tail gets“sucked back” over theopening whenblood aspiration is attempted

Flushing:

tail gets pushed

aside by the

positive

pressure of

infusing

Hill, J, et al., Vascular Access 2013:7(Supplement 1)

KDOQI 2006 Clinical Practice Guidelines and Clinical Practice Recommendations, Vascular Access, 2006



Partial Occlusion1

Decreased ability to infuse

fluids; resistance with flushing

and aspiration

Sluggish flow through the

catheter

May be caused by

intraluminal thrombus or fibrin

sheath

Withdrawal Occlusion1

Inability to aspirate blood but

ability to infuse without any

resistance

May be caused by fibrin tail

May result in line revseral2

Complete Occlusion1

Inability to infuse or

withdraw blood or fluid




42

© Penny Offer, CRNI © Penny Offer, CRNI




Please refer to your institution’s policies regarding

unblocking a central line.

Steps it may include in are:

• Troubleshoot (flushing, repositioning, etc…)

• Use an antithrombolytic agent (Alteplase aka tPA)

• Checking placement using a lineogram/Chest X-Ray



References



Mokrzycki MH, et al. Kidney International Sept 2010 78:1218–31

Salgado OJ. Vascular Access for Hemodialysis. Overview and Emphasis on Complications 2013.

Vaccharajani TJ. Atlas of Dialysis Vascular Access 2010.

http://thenurseszone.com/wp-content/uploads/2015/08/Recognizing-Preventing-and-troubleshooting-central-

line-complications..pdf

The Hospital for Sick Children: Appendix 3A V2 Standard Work Line Entry Hub Scrub

Appendix 3B Standard Work CVAD Dressing Change

Implementation Toolkit CLABSI mysickkids.pdf

http://thenurseszone.com/wp-content/uploads/2015/08/Recognizing-Preventing-and-troubleshooting-central-line-complications..pdf

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